Publicaciones científicas

Hypotension-Avoidance Versus Hypertension-Avoidance Strategies in Noncardiac Surgery : An International Randomized Controlled Trial

01-may-2023 | Revista: Annals of Internal Medicine

Maura Marcucci  1 , Thomas W Painter  2 , David Conen  1 , Vladimir Lomivorotov  3 , Daniel I Sessler  4 , Matthew T V Chan  5 , Flavia K Borges  1 , Kate Leslie  6 , Emmanuelle Duceppe  7 , María José Martínez-Zapata  8 , Chew Yin Wang  9 , Denis Xavier  10 , Sandra N Ofori  1 , Michael Ke Wang  1 , Sergey Efremov  11 , Giovanni Landoni  12 , Ydo V Kleinlugtenbelt  13 , Wojciech Szczeklik  14 , Denis Schmartz  15 , Amit X Garg  16 , Timothy G Short  17 , Maria Wittmann  18 , Christian S Meyhoff  19 , Mohammed Amir  20 , David Torres  21 , Ameen Patel  22 , Kurt Ruetzler  4 , Joel L Parlow  23 , Vikas Tandon  22 , Edith Fleischmann  24 , Carisi A Polanczyk  25 , Andre Lamy  1 , Raja Jayaram  26 , Sergey V Astrakov  27 , William Ka Kei Wu  5 , Chao Chia Cheong  9 , Sabry Ayad  4 , Mikhail Kirov  28 , Miriam de Nadal  29 , Valery V Likhvantsev  30 , Pilar Paniagua  31 , Hector J Aguado  32 , Kamal Maheshwari  4 , Richard P Whitlock  1 , Michael H McGillion  1 , Jessica Vincent  1 , Ingrid Copland  1 , Kumar Balasubramanian  1 , Bruce M Biccard  33 , Sadeesh Srinathan  34 , Samandar Ismoilov  3 , Shirley Pettit  1 , David Stillo  1 , Andrea Kurz  4 , Emilie P Belley-Côté  1 , Jessica Spence  1 , William F McIntyre  1 , Shrikant I Bangdiwala  1 , Gordon Guyatt  35 , Salim Yusuf  1 , P J Devereaux  1 ; POISE-3 Trial Investigators and Study Groups


Background: Among patients having noncardiac surgery, perioperative hemodynamic abnormalities are associated with vascular complications. Uncertainty remains about what intraoperative blood pressure to target and how to manage long-term antihypertensive medications perioperatively.

Objective: To compare the effects of a hypotension-avoidance and a hypertension-avoidance strategy on major vascular complications after noncardiac surgery.

Design: Partial factorial randomized trial of 2 perioperative blood pressure management strategies (reported here) and tranexamic acid versus placebo. (ClinicalTrials.gov: NCT03505723).

Setting: 110 hospitals in 22 countries.

Patients: 7490 patients having noncardiac surgery who were at risk for vascular complications and were receiving 1 or more long-term antihypertensive medications.

Intervention: In the hypotension-avoidance strategy group, the intraoperative mean arterial pressure target was 80 mm Hg or greater; before and for 2 days after surgery, renin-angiotensin-aldosterone system inhibitors were withheld and the other long-term antihypertensive medications were administered only for systolic blood pressures 130 mm Hg or greater, following an algorithm. In the hypertension-avoidance strategy group, the intraoperative mean arterial pressure target was 60 mm Hg or greater; all antihypertensive medications were continued before and after surgery.

Measurements: The primary outcome was a composite of vascular death and nonfatal myocardial injury after noncardiac surgery, stroke, and cardiac arrest at 30 days. Outcome adjudicators were masked to treatment assignment.

Results: The primary outcome occurred in 520 of 3742 patients (13.9%) in the hypotension-avoidance group and in 524 of 3748 patients (14.0%) in the hypertension-avoidance group (hazard ratio, 0.99 [95% CI, 0.88 to 1.12]; P = 0.92). Results were consistent for patients who used 1 or more than 1 antihypertensive medication in the long term.

Limitation: Adherence to the assigned strategies was suboptimal; however, results were consistent across different adherence levels.

Conclusion: In patients having noncardiac surgery, our hypotension-avoidance and hypertension-avoidance strategies resulted in a similar incidence of major vascular complications.

CITA DEL ARTÍCULO  Ann Intern Med. 2023 May;176(5):605-614. doi: 10.7326/M22-3157.  Epub 2023 Apr 25.